Provider Demographics
NPI:1306076518
Name:ERNST, DAVID D (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:D
Last Name:ERNST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 INSIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2193
Mailing Address - Country:US
Mailing Address - Phone:618-628-2903
Mailing Address - Fax:618-628-2913
Practice Address - Street 1:735 INSIGHT AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2193
Practice Address - Country:US
Practice Address - Phone:618-628-2903
Practice Address - Fax:618-628-2913
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010290152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010290Medicaid
IL1295778587OtherNPI GROUP
IL046010290Medicaid
ILCK5585Medicare PIN